Is Manual Therapy in Danger of Becoming Too Prescriptive?

Donal discusses whether osteopaths, physiotherapists and chiropractors are becoming middle men between databases of pre-prepared exercise plans and their patients. 


Nowadays manual therapists are being constantly bombarded by new guidelines from  National Institute of Cinical Excellence (NICE), governing bodies and new research that always seems to be telling us exactly how to treat and manage our patients.

The product of their research seems to restrict or dictate to therapists, telling them what their patients need. On the face of it you might assume that this is a good thing however I think the pendulum has swung too far in the direction of evidence based practise and that it is damaging to the reputation of therapists and the health of the patient they treat. The result of new guidelines and protocols is that the 3 or 4 years of training that a physiotherapist or an osteopath go through to develop diagnostic skills, learn how to deliver hands on treatment and devise patient tailored management plans are, in my opinion, being undermined.

Below is a scenario example of how manual therapists can fall into the trap of labelling a patient with a condition, treating that label and not the patient as a person.

Tennis elbow is a condition common amongst tennis players, trades men and women  and musicians using bows. The action they all have in common is that their lifestyles place the muscles and ligaments in the forearm under repeated stress.Following guidelines set out by NICE and the NHS Choices website a patient suffering tennis elbow gets shuffled onto a conveyor belt of treatments. This begins with painkillers, and anti inflammatories and ending in surgery. In the middle physiotherapy is mentioned as being useful in the treatment of tennis elbow (singly promoting physiotherapy as the only providers of massage and manipulation is a discussion for another day). Inevitably the under pressure NHS physiotherapist is likely to issue the patient with an exercise plan often without any hands on treatment. This does not help the reputation of physiotherapy, believe me I have heard many stories from dissatisfied NHS physiotherapy patients, nor does it help the patients, who often report feeling unappreciated, and dispirited which affects their compliance with exercise programmes. Worsened by the common lack of continuity when the patient returns for a follow up appointment and gets seen by another practitioner. This is not the fault of the physiotherapist, they can only work within the time restraints that they are placed under and the ever growing waiting list.

How you might ask? Well for nearly any musculoskeletal problem a patient might present with there  a ‘protocol’ available online. These are inevitably all exercise based plans. So are osteopaths, physiotherapists and chiropractors just becoming a middle man between a database of pre-prepared exercise plans and a patient presenting with a pain?  Hopefully not.


What is more interesting than the condition itself is asking why has it occurred now? This is an underpinning osteopathic philosophy that many other manual therapists are now beginning to ask. It is not only interesting but it is vitally important in the process of helping a patient recover and stay symptom free. Sometimes it is obvious and has a clear onset for example a trauma but other times it is more insidious. Treating the symptoms of tennis elbow for example with anti inflammatories is helpful however it doesn’t address the factors that lead to the injury in the first place. This might provide a patient might experience relief in the short term. However, if the factors that predisposed the injury in the first place aren’t addressed it is likely to assume the injury will reoccur again.

You could argue that the protocols include exercises and stretches that will help to address these predisposing or maintain factors. I would argue that any standardised exercise plan will again only dehumanise a patient- it addresses their label/ diagnosis without treating them as an individual. It won’t address their unique body shape, bio-mechanics, lifestyle and hobbies. Collectively we call these bio-psychosocial factors and it is in addressing these factors that osteopaths must excel to improve our patients health in the short and long term. Any manual therapy practitioner is capable of managing patients in this way however a bio-psychosocial approach is instilled within osteopathic students whereas the more reductionist approach is used stereotypically by physiotherapists. 

Of course there should be an evidence base for what techniques are used in the management of a patient however it shouldn’t undermine the autonomy of the practitioner delivering it. Relying on protocols is in my opinion a skill-less, watered down version of what osteopaths, physiotherapists and chiropractors were trained to do. It doesn’t deliver the best care for the patient and when it doesn’t deliver the results intended it is our own reputations that will suffer. 

Poor Billy Joe has taken evidence based practise too far.


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